[HSF] Another Victory for the LAD Stent.....

Sat Feb 9 20:23:45 EST 2008

Left thoracotomy is worth considering for redo with patent LIMA to LAD. The lateral wall of the heart can be nicely exposed and even the PDCA. It is not so easy in very obese patients or very emphysematous patients. The axillary artery is good for proximal anastomosis for SVG or radial artery. The LIMA may be used for a proximal anastomosis and only a short conduit is needed for the obtuse marginal. John Flege 

-----Original Message-----
From: Edward Bender <ebender001 at charter.net>
To: OpenHeart-L at lists.hsforum.com
Sent: Sat, 9 Feb 2008 5:54 pm
Subject: Re: [HSF] Another Victory for the LAD Stent.....

> Either we believe in something or we don't.
This is not an "either or" situation.  I think repeat CABG can be a
difficult operation, with less likelihood for complete revascularization.
Also, there is an albeit small but real risk of damage to the LIMA graft. On
balance, if a catheter based approach can avoid the risks of repeat surgery
with a good likelihood of symptom relief, then I'm all for it. If, on the
other hand, the risks of PCI are higher than that of surgery, then I would
push for repeat CABG.

I just know that, in my hands, sometimes even finding a decent OM branch to
graft in a redo is difficult.  I have also seen cases where the LIMA has
been left completely untouched, yet, by retracting the heart to get to the
OM territories, the LIMA kinks, causing ischemia, which is sometimes not
temporary.

> I suspect if a redo CABG was a much easier operation we would have a different
> view.
And if the queen had balls, she'd be king!

Ed Bender, MD

On 2/9/08 4:38 PM, "Ani Anyanwu" <anianyanwu at hotmail.com> wrote:

> I find it very interesting to observe how willing surgeons are to give up
> repeat revascularization in the setting of prior CABG to the cardiologist and
> how the stent, which we all despise as primary therapy, suddenly becomes an
> excellent tool in setting of vein graft disease or new native disease.
>  
> Either we believe in something or we don't. If a patient has severe circ and
> right  disease we argue CABG is better than DES but when that patient is a
> reoperation, we question the role for surgery.
>  
> I must say I have seen a few of these diseased vein grafts either
> angiographically, at surgery or at autopsy. I may be naive but I find it hard
> to believe how a stent (in a vein graft) can be the solution for vein graft
> disease. Even if effective how about the 50% or so of patients who develop
> recurrent angina not because of vein graft disease but progression of native
> disease, don't those native vessels do better with CABG anymore?
>  
> I suspect if a redo CABG was a much easier operation we would have a different
> view.
>  
> Ani
>  
>  
> 
> 
> 
>> Date: Sat, 9 Feb 2008 15:38:36 -0600> Subject: Re: [HSF] Another Victory for
>> the LAD Stent.....> From: ebender001 at charter.net> To:
>> OpenHeart-L at lists.hsforum.com> CC: > > If I remember correctly, there was
>> crossover to redo CABG for refractory> symptoms in the presence of
>> un-stentable vessels. This has been my limited> experience, also. The usual
>> scenario is a patent LIMA to the LAD, occluded> native LCx and RCA, with
>> ungrafted vessels, occluded grafts, or severely and> diffusely diseased
>> grafts so that a filter wire would not be protective of> embolization. I
>> usually have to do 2 or 3 of these types of cases a year.> The most
>> distressing are the ones with severely diseased patent grafts going> to the
>> OM branches. I would bet most of these patients come out of the OR> with ST
>> segment elevation.> > Ed Bender, MD> > > On 2/9/08 2:51 PM, "Hgrmd at aol.com"
>> <Hgrmd at aol.com> wrote:> > > Ani,> > To be honest, I didn't critically analyze
>> the paper from CCF. They very> > well could have done some arcane data
>> massage to prove a point. However,> > their conclusions basically support the
>> policies of the surgeons in my group> > as > > well as the referring
>> cardiologists. It's rare that we do a redo stand alone> > CABG when there is
>> a well functioning LIMA to the LAD. For one thing, the> > interventionalists
>> can generally do enough PCI to get by. If they can't, the> > patient is
>> usually treated medically. Since I haven't done a stand alone> > CABG > > so
>> far this year, I can't speak authoritatively. However, I do believe it's> >
>> rare that we reoperate when there is a good LIMA to the LAD.> > > > Hal> > >
>> > > > > > **************Biggest Grammy Award surprises of all time on AOL
>> Music.> > 
>> (http://music.aol.com/grammys/pictures/never-won-a-grammy?NCID=aolcmp00300000
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